Exclude infection in patients with a failed TKA secondary to arthrofibrosis

Issue: March 2013

ByJavad Parvizi, MD, FRCS

ByPaul M. Lichstein, MD, MS

Stiffness due to arthrofibrosis following total knee arthroplasty remains a common problem facing orthopedic surgeons and may incur disabling consequences for patients.

Reports on the incidence of arthrofibrosis following total knee arthroplasty (TKA) vary. However, a comparison of our own investigations in 2002 and 2012 reveals that great strides have been made in reducing the percentage of revisions performed for arthrofibrosis. In our most recent series, arthrofibrosis was identified as the failure mechanism in 4.5% of all primary revision surgeries compared with 16.9% of early revisions (less than 2 years from the primary procedure) and 12.2% of late revision (more than 2 years from the primary procedure) cases in our 2002 series.

Arthrofibrosis

Javad Parvizi

Although the development of arthrofibrosis is multifactorial and highly dependent upon preoperative range of motion, surgical technique, implanted prosthesis and postoperative rehabilitation, a common mechanistic pathway has been elucidated. The identified pathophysiology involves abnormal activation and the expression of pro-oxidant enzymatic activity (myeloperoxidase), aberrant overproduction of reactive oxygen and nitrogen species, and disregulation of p53.

Additionally, certain genetic profiles may predispose patients to such upregulation and it may develop in response to infection. Regardless, the result of this cascade is fibroblast proliferation, excessive scar formation and even heterotopic ossification. Therefore, arthrofibrosis may represent an isolated and inappropriately robust reaction in an aseptic inflammatory milieu or perhaps from an infectious pathogen.

Paul M. Lichstein

Revision surgeries

Advancements in surgical technique, implant design and rehabilitation protocols have succeeded in reducing the number of revision surgeries performed for arthrofibrosis. But vigilance should be maintained for the presence of infection. A recent review of our institutional data revealed rates of infection were significantly higher in patients with arthrofibrosis undergoing manipulation under anesthesia when compared to overall rates of infection following primary TKA, and this concern has been raised by others.

Certainly, further investigation is needed to clearly delineate the relationship. However, when evaluating the postoperative TKA patient with failure secondary to arthrofibrosis, a work-up to exclude infection should always be initiated.

References:

Sharkey PF. Insall Award paper. Why are total knee arthroplasties failing today? Clin Orthop Relat Res. 2002;(404):7–13.
Freeman TA. Fibrogenesis Tissue Repair. 2009;doi:10.1186/1755-1536-2-5.
Parvizi J. J Bone Joint Surg Am. 2006;doi:10.2106/JBJS.F.00608.
Su EP. Orthopedics. 2010;doi:10.3928/01477447-20100722-48.

For more information:

Javad Parvizi, MD, FRCS, editor of Infection Watch, can be reached at the Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; email: parvj@aol.com.
Paul M. Lichstein, MD, MS, can be reached at the Rothman Institute at Thomas Jefferson University, Sheridan Building, 10th Floor, 125 South 9th St., Philadelphia, PA 19107; email: Paul.Lichstein@rothmaninstitute.com.
Disclosures: Parvizi is a consultant to Zimmer, Smith and Nephew, 3M and Convatec. Lichstein has no relevant financial disclosures.